New form to be completed daily unless authorized by the office. We cannot administer any medications without the form.
Complete form, printing clearly and in INK.
MEDICATIONS MUST BE PRE-MEASURED!!!!!
Child’s Name: ________________________ DOB: _________ Date:______________
Child’s Teacher: ________________________
Name of Medication: __________________________________ Dosage: ___________ Is this a prescription? Yes ______ No ______ Refrigerate? Yes____ No____
Instructions:
_____________________________________________________________________________
If your child is sleeping, do you want us to wake them to give medicine? Yes _____ No ____
Time medication was last given outside of Day School: ________
Times administered during Day School hours:
____ AM PM Teacher administering medication: ___________________________
Date:_________ Witness: ___________________________________________
____ AM PM Teacher administering medication: ___________________________
Date:_________ Witness: ___________________________________________
____ AM PM Teacher administering medication: ___________________________
Date:_________ Witness: ___________________________________________
____ AM PM Teacher administering medication: ___________________________
Date:_________ Witness: ___________________________________________
____ AM PM Teacher administering medication: ___________________________
Date:_________ Witness: ___________________________________________
Original- home daily. Copy- student’s office file.